Enteral Tube Feeding Information Pack

for Healthcare Professionals

Authors: Managed Clinical Network for the West of Scotland Paediatric Gastroenterology, Hepatology and Nutrition (MCN WoSPGHaN) Enteral Feeding Information Group

Approved by: MCN WoSPGHaN Enteral Feeding Strategy Group MCN WoSPGHaN Education Group MCN WoSPGHaN Strategy Group

Date approved: December 2012 Date for review: December 2015 Replaces previous version: [if applicable]

DISCLAIMER The content of this information pack has been produced following consensus from healthcare professionals across the West of Scotland and with reference to current evidence available. Every effort has been made to ensure that the recommendations are accurate, complete and up to date. However, it should be noted that the final responsibility lies with the individual healthcare professional carrying out the clinical procedures.

© MCN WoSPGHaN

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Contents Page Glossary iii Section 1 Introduction 6 Objectives 6 Enteral Tube Feeding 6 Indications for Enteral Tube Feeding 6 Types of Enteral Feeding Tubes 7 Nasogastric Tubes 7 Gastrostomy Tubes 8 Jejunal Tubes 9 Methods of Feeding 11 Gravity Bolus Feeding 11 Pump Bolus Feeding 11 Continuous Pump Feeding 11 Enteral Equipment and Patient Safety 11 Section 2 Nasogastric Feeding 13 Procedure for Passing a Nasogastric Feeding Tube 13 Potential Problems when Passing a Nasogastric Feeding Tube 15 Checking the Position of a Nasogastric Feeding Tube 16 Potential Problems when Checking Position of Nasogastric Feeding Tube 17 Documentation of pH in Hospitals 18 Bolus Feeding via a Nasogastric Feeding Tube 19 Pump Feeding via a Nasogastric Feeding Tube 21 Section 3 Gastrostomy Feeding 24 Bolus Feeding via a Gastrostomy Tube 24 Pump Feeding via a Gastrostomy Tube 26 Section 4 References 28 Acknowledgments 29 Section 5 Appendix 1. Administering Medication via an Enteral Feeding Tube 31 Appendix 2. Feed Hygiene 32 Appendix 3. Supporting Information 33

Oral Care 33 Single Use Equipment 33 Colour Blindness 33

Appendix 4. Guidance for Staff to Reduce Risk of Strangulation Caused by Enteral Feeding Lines 34

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GLOSSARY Aspiration Taking a sample of stomach (gastric) contents for

pH testing

Balloon A balloon is filled with water, which sits inside the

stomach and stops the gastrostomy tube from

falling out.

Balloon Port Valve in gastrostomy tube to insert water into the

balloon

Bolus Feeding A volume of feed delivered using a syringe over a

short period of time

Clinical Waste Used medical equipment for disposal

Continuous Feeding A volume of feed delivered by a feeding pump at a

constant rate over a period of time

Decanting Pouring feed from original container into another

container

External Fixator A devise that holds the gastrostomy tube against

the skin

Gastric Contents Stomach contents

Giving Sets Plastic tubing that delivers feed

pH indicator paper Paper or strip that measures the amount of acid in

stomach contents

Single Use Use once and then discard

Buried Bumper Stomach lining grows around internal disc

Single Patient Use Can be used more than once on one patient only

Stoma Tract created surgically, into the body from outside

Section 1

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INTRODUCTION The purpose of this pack is to provide information to all health care professionals across the West of Scotland that will enable them to deliver safe care and delivery of enteral tube feeding to children and young people. Adopting a consistent approach across the region will promote a seamless service for children and young people and aims to reduce the potential risks associated with enteral tube feeding. OBJECTIVES To provide information on enteral tube feeding that reflects current thinking and

evidence based practice to healthcare professionals in the West of Scotland. To promote a consistent approach to enteral tube feeding for children/young people

across the West of Scotland. To promote safe delivery and reduce potential risks of enteral tube feeding in

children/young people. To outline best practice for procedures relating to enteral tube feeding. ENTERAL TUBE FEEDING The number of children/young people receiving enteral tube feeding continues to grow annually (Ardill et al, 2010 and Paxton et al, 2012). Good nutrition is necessary to sustain body functions, promote growth and encourage tissue repair and provide energy for physical activity. If a child/young person has difficulty swallowing they will be unable to achieve an adequate oral intake and feeding via a tube may be necessary. Research has found that almost all parents report a significant improvement in their child/young person’s health and growth as a result of tube feeding (Sullivan et al, 2005). In 2007, Quality Improvement Scotland outlined best practice for children receiving enteral feeding in the community (QIS, 2007). Recently reports have highlighted the risks associated with enteral tube feeding however, these complications are rare and can be minimised by adhering to evidence based best practice (National Patient Safety Agency, 2005a, 2011, 2012a, 2012b). Indications for Enteral Feeding Difficulty achieving adequate nutrition associated with or due to any of the following may require tube feeding 1. Faltering growth 2. Inability to swallow / Unsafe swallow 3. Severe Oesophageal Reflux / Vomiting 4. Distress during feeding 5. Prolonged feeding times / Unable to complete feeds due to underlying disease 6. Recurrent aspiration 7. Neurological dysfunction 8. Special diets 9. Critical Illness

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This list is not exhaustive and there may be other reasons why enteral tube feeding is required. Enteral tube feeding is most likely to be administered via nasogastric or gastrostomy tubes. These can vary in type, size and fittings. Types of Enteral Feeding Tubes Nasogastric Tubes Nasogastric tubes are fine bore tubes with a small internal diameter and are commonly used for short to medium term enteral feeding. These tubes are passed via the nose into the stomach and are available in two main types: Short-term Tubes These tubes have historically been manufactured from polyvinylchloride (PVC) and can remain in place for between 7-10 days, dependant on manufacturer’s guidelines. More recently polyurethane tubes without guide wires have been available and can be left in place for up to 30 days. All these tubes are single use and should the tube become dislodged it should be discarded and replaced with a new tube. Long-term Tubes These tubes are made of polyurethane and have a guide-wire to aid the passing of the tube. Once the tube has been passed, the guide-wire is removed and should be kept in a clean safe place as it will be required should the tube become dislodged. This tube can normally remain in situ for approximately eight weeks dependent on manufacturer’s guidance. Within this time, the tube can be cleaned and re passed. Cleaning of the tube should also be in accordance with manufacturer’s guidance and local policy. Gastrostomy Tubes A gastrostomy is a surgical opening (stoma) between the skin and stomach, which can be used for long term feeding via a gastrostomy tube. There are different types of gastrostomy tubes, the most common ones are described and shown on the pages that follow:

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Percutaneous Endoscopic Gastrostomy (PEG) A PEG tube is inserted during a simple surgical procedure. The tube is passed down the throat into the stomach using an endoscope. The tube is then brought out through a surgically created tract between the stomach and abdominal wall. A small disc at one end of the tube secures the tube inside the stomach. Once placed, an external fixator device, a clamp and a feeding connector are then fitted to the external part of the tube. These tubes generally last around 18 months or as recommended by the manufacturer. Balloon Inflated Gastrostomy Tube There are two types of balloon devices. These are usually placed in a formed surgical tract and are shown below: Balloon Gastrostomy Tube

This tube is held in place in the stomach by a balloon filled with water and an external fixation plate. All tubes will have a reverse luer lock feeding connector and a valve for inflating the balloon.

Low profile device (Button) This is a small device that is held in place in the stomach by a balloon filled with water. It requires an extension set for the administration of medications or feeds. Nothing should be inserted directly into the button device except for the appropriate extension set, as anything else will damage the valve.

Both balloon and low profile gastrostomy devices will require the water in the balloon to be changed on a weekly basis. These devices will require to be replaced every 3-6 months depending on manufacturer’s guidance and the individual patient. These devices can be replaced without a surgical procedure, by simply removing the water from the balloon, removing the tube/button then replacing it with a new tube/button and inflating the balloon with cooled boiled water. Balloon inflated gastrostomy devices should only be changed by someone who has been fully trained and is competent in this procedure. Jejunal Tubes These feeding tubes are used when there is a medical requirement to deliver feeds directly into the small intestine (jejunum) totally by-passing the stomach.

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Nasojejunal tube This is similar to a long-term nasogastric tube, but longer. It is usually passed via the nose and through the stomach into the jejunum under fluoroscopic guidance in the radiology department. Gastrojejunostomy This looks similar to a low profile button gastrostomy tube but it has a longer tube, which extends into the jejunum through a pre-existing tract. It has 2 lumens one for feeding and the other for gastric decompression. Transgastric–Jejunal Double Lumen Feeding Tube These can be placed surgically, endoscopically or radiologically. They have double lumens, one for feeding and the other for gastric decompression. Surgical Jejunostomy These tubes are surgically inserted through the abdominal wall and directly into the small bowel.

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METHODS OF FEEDING Gastrostomy and nasogastric feeds can be given in the form of bolus, continuous feeding or a combination of both. The method chosen will be the one that best meets the needs of the child/young person. Jejunal feeding is always administered by continuous pump feeding over several hour’s as the stomach reservoir is not used. Gravity Bolus Feeding

This is normally a pre-determined volume of feed given via an open syringe. The feed should take around 15-30 minutes, depending on the feed type and volume being given and the individual child/young person.

Pump Bolus Feeding

This is also a pre-determined volume of feed given over a short period of time but at a controlled and steady rate via a feeding pump. The period of feeding will be planned for each individual. Continuous Pump Feeding

This is where a feed is administered at a controlled rate over a longer period of time via a feeding pump.

ENTERAL EQUIPMENT AND PATIENT SAFETY The National Patient Safety Agency (NPSA, 2005a, 2005b, 2007, 2011, 2012a and 2012b) has issued a number of patient safety alerts regarding patient safety and enteral tube feeding. This guidance requires the universal adoption of dedicated ‘enteral systems’, which are incompatible with intravenous connections, thereby reducing the potential risk of enteral medicines/feeds being administered intravenously, which can prove fatal. The NPSA recommendations also state that pH indicator strips used for checking enteral tube position must be CE marked for the testing of human gastric aspirate. Further guidance from the NPSA (2011) highlighted that confirmation of tube position using pH testing and observed length of tube is fundamental but also that if x-ray confirmation is required the individuals interpreting those x-rays must be competent. Local guidance regarding this should be followed. Home enteral tube feeding also poses a risk of entanglement in lines and potential strangulation (NPSA, 2012b). This must be highlighted to parents prior to discharge and the steps that should be taken in order to minimise risk i.e. tubes being positioned out of the leg of a babygro etc. Appendix 4 provides some guidance on risk reduction measures that aim to promote patient safety for those receiving enteral feeding overnight.

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Section 2

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NASOGASTRIC FEEDING Introduction Nasogastric feeding is generally used for children and young people who require short-term nutritional support. The following guidance outlines the procedure required to pass a nasogastric tube. Procedure for Passing a Nasogastric Feeding Tube Equipment Required

Clean tray/trolley/surface Naso-gastric feeding tube (correct type, size and length) 50ml enteral (‘purple’) syringe pH indicator paper (CE marked for human gastric aspirate use) Cooled boiled water/sterile water Tape to secure tube to face* Scissors Non-sterile gloves and apron (paid carers and nursing staff) Cup of water and straw, sick bowl and tissues (if age appropriate) * There are different tapes that can be used to secure the tube to the side of the face. Check if the child is allergic to tapes prior to making a decision about which tape to use. The Procedure 1. Ensure there is no contraindication to nasal tube insertion. 2. Ensure everything you need has been collected and is near to hand. 3. Explain the procedure to parents/child/young person and gain consent. 4. Check the nostrils to see if either is clearer and choose the clearest. (Alternate nostrils each time you change the tube). 5. Ensure that the child/young person is comfortable

a. Babies can be wrapped in a blanket or towel to help keep them secure and placed in a cot.

b. Older children may prefer to sit up with their head tilted slightly forward.

6. Wash and dry hands thoroughly and put on apron and gloves. 7. Measure the length that the tube needs to be inserted to by holding to tip of the tube

at the tip of the nose, to the child’s ear lobe and then to the base of the breastbone (xisphisternum). This measurement is referred to as the NEX measurement (Nose-Ear-Xisiphisternum).

Mark this on the tube or keep your fingers on the point where you measured and

make a note of the number marker.

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8. Wet the tip of the tube if required, with some cooled boiled/sterile water.

9. Pass the tube using the steps below:

a. Insert the tip of the tube into the chosen nostril. b. Slide backwards along the floor of the nose. c. If you feel any obstruction, pull the tube back, turn it slightly and advance tube

again. d. If obstruction is felt again try the other nostril. e. As the tube passes to the back of the nose, ask the child/young person to take sips

of water if able, this will help tube go down. f. If the tube is being passed on a baby give them a dummy, if they have one. g. Advance the tube until you reach the point you measure.

10. Secure the tube to the child’s face using the supplied tape. An indelible ink marker can be used to mark the tube at the nostril.

11. Check position of the tube following procedure on page 16.

12. If using a long-term tube follow the above procedure before removing the guide wire (you may need to lubricate the guide wire first by flushing with sterile/cooled boiled water, please follow manufacturers guidance). The tube can only be flushed with water if gastric position has been confirmed (NPSA, 2012a). The wire is then removed once the tube is passed but must be kept in case the tube has to be re-passed.

13. Attach the barrel of an enteral 50ml syringe to the end of the tube and flush with the recommended amount of cooled boiled water /sterile, when position has been confirmed.

14. Dispose of waste in line with local policy (at home this would be in domestic household waste).

15. Wash and dry hands.

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16. Ensure documentation is completed (including; make, size and length of tube used, pH reading, observed length of tube at the nose).

17. In hospital if x-ray confirmation is required due to a pH greater than 5.5 or failure to obtain an aspirate this should be clearly documented and the tube labelled (‘DO NOT USE’) until a competent practitioner has reported and documented x-ray findings (please follow local protocol).

Potential Problems when Passing a Nasogastric Feeding Tube

Vomiting during the passing of the tube.

This can happen occasionally, if it does, stop procedure, remove the tube and place child or young person on their side. Allow them to settle and re-attempt procedure or seek advice.

Blood staining

This can happen if the tube scrapes the inside of the nose when passing the tube. When you first see this it can be upsetting but it is usually not a problem. Reassure the child or young person.

Nose-bleeds

These can happen and if becomes more severe stop the procedure. Wait until the nosebleed settles before re-passing the tube. It is advisable to retry using the other nostril but if it persists seek medical advice.

Coughing or choking

If the child coughs or appears to have difficulty breathing during the procedure – STOP. Withdraw tube and seek medical help if you are concerned.

Checking the Position of a Nasogastric Feeding Tube Introduction The tube position must always be checked before use, using indicator pH paper. NG tubes can often become dislodged and therefore it is important that the position of the tube is always checked in the following circumstances: 1. Prior to each bolus feed 2. Prior to commencing continuous feeds 3. Prior to administration of medicines out with feeding times 4. After coughing / retching / vomiting episode 5. If the tube appears to have changed in length (this should be regularly checked and

recorded) 6. If child develops signs of breathing difficulties such as breathlessness, stridor,

cyanosis or wheezing

Equipment Required

Clean tray/trolley/surface 50ml enteral (‘purple’) syringe pH indicator paper (CE marked for human gastric aspirate use)

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Cooled boiled water/sterile water Non-sterile gloves and apron (paid carers and nursing staff) The Procedure

1. Ensure everything you need has been collected and is near to hand.

2. Explain the procedure to parents/child.

3. In older children it is best to do the procedure sitting up, with their head facing you. If this is not possible, lie them down on their back with their face looking upwards.

4. Wash and dry our hands thoroughly and put on apron and gloves.

5. Attach an enteral 50ml syringe to the end of the NG tube and gently withdraw a small amount of stomach contents (this is called an aspirate).

6. Syringe a drop of the contents onto the pH indicator paper, ensuring that all the test’ area is covered. Wait 10-60secs (or as instructed by the manufacturer). Hold the pH indicator paper and check against the colour chart on the container.

7. A pH reading of less than or equal to ph 5.5 means the tube is in the correct position (see section on ‘checking the position’ for more information).

8. If the pH is either 5 or 5.5. It should be verified by another person.

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9. The reading of a pH 5.5 or less is very important. The tube position should always be checked before every use.

Potential Problems when Checking Position of Nasogastric Feeding Tube Unable to aspirate If you are unable to aspirate, try again after attempting the following: - Check the length of the tube at nose is the same as it has been previously recorded.

If the tube has just been placed try advancing by a further few centimetres and try again. Remember to document the observed length of the repositioned tube and tape it securely.

Using an enteral syringe plunge a small amount of air into the nasogastric tube as the end of the tube may be lying against the stomach wall. However, do not use air auscultation to determine position of nasogastric tube.

Provide the child with a drink of water (orally) (unless there are medical reasons why they shouldn’t have this) and wait approximately 30 minutes.

Gently rock smaller children side to side if the child will tolerate. Lay the child on their left hand side for approximately 30mins. Check the length of the tube at nose is the same as it has been previously recorded.

If the tube has just been placed try advancing by a further few centimetres and try again. Remember to document the observed length of the repositioned tube and tape it securely.

pH reading is greater than 5.5 This may be due to certain medications that the patient is receiving Check if the tube appears dislodged. It may be necessary to repass the tube if this is

the case. If the child or young person has recently had a feed, large quantities of milk will

register a high pH. Leave checking the pH for a further 30minutes. If the child can drink orally then give them a drink of water and wait for

approximately 30 minutes before re-testing.

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Documentation of pH testing in Hospital A chart should be kept by the child’s bedside, which documents the following: 1. Observed length of tube 2. Time aspirate was obtained 3. The pH of the aspirate 4. Who checked the aspirate 5. Action taken if pH >5.5 6. The amount and type of feed given

Whilst the child/ young person is in hospital and it is either difficult to obtain an aspirate or the pH reading is greater than 5.5, an x- ray may have to be taken to confirm the position of the nasogastric tube. This will be interpreted by someone competent to do so and must be documented. Please follow local guidance. Bolus Feeding via a Nasogastric Feeding Tube Introduction Bolus feeding via a nasogastric tube delivers a prescribed volume of feed over a short period of time using a syringe at regular intervals. The tube position should always be checked prior to each bolus feed following the procedure described on page 16.

Equipment Required

Clean tray/trolley/surface 50ml enteral (‘purple’) syringe pH indicator paper (CE marked for human gastric aspirate use) Cooled boiled water/sterile water Non-sterile gloves and apron (paid carers and nursing staff) The feed. Check the feed including feed type and expiry date. If the feed is curdled

don’t use. Opened containers of feed should be stored in a fridge and discarded after 24 hours)

Any extension set or additional feeding equipment

The Procedure

1. Ensure that everything has been collected and is near to hand.

2. Inform the child/ young person the feed is about to start.

3. Position the child/young person in a sitting position. If this is not possible their head should be elevated by at least one pillow. For babies, place the pillow underneath the top of the mattress.

4. Wash and dry your hands thoroughly, put on apron and gloves.

5. Test the position of the tube (please see page 16).

6. To flush the tube, remove any stoppers and attach the barrel of an enteral 50ml syringe to the tube.

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7. Pour prescribed amount of cooled boiled water / sterile water into syringe barrel.

8. After the water has been administered, pour feed into the syringe.

9. Continue pouring feed into syringe barrel at rate tolerated by child/ young person.

10. Do not use the plunger to push the water or feed. If the feed is going too fast lower the syringe, if it is too slow then raise the syringe. The average time it should take for the feed to run through is 15-30mins.

11. Once the feed is completed flush the tube with the prescribed volume of cooled boiled / sterile water as per individual child’s care plan.

12. Remove syringe and replace stopper.

13. If a reusable syringe is used, wash and store as per manufacturers instructions.

14. Dispose of used equipment appropriately.

15. Wash and dry hands thoroughly.

16. Remember to complete bedside documentation if child in hospital.

If the child or young person starts coughing or vomiting during the feed, then stop the feed. Once they have settled, retest the position of the tube again (following procedure on page 16) before recommencing feed.

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Pump Feeding via a Nasogastric Feeding Tube Introduction Pump feeding via a nasogastric tube delivers a prescribed volume of feed over a long period of time using an enteral feeding pump. The tube position should always be checked prior to commencing the feed following the procedure described on page 16. Equipment Required Clean tray/trolley/surface 50ml enteral (‘purple’) syringe pH indicator paper (CE marked for human gastric aspirate use) Cooled boiled water/sterile water Non-sterile gloves and apron (paid carers and nursing staff) The feed. Check the feed including feed type and expiry date. If the feed is curdled

don’t use. Opened containers of feed should be stored in a fridge and discarded after 24 hours

Enteral feeding pump and giving set

The Procedure

1. Ensure that everything you need has been collected and is near to hand.

2. Inform the child/ young person you are now going to start the feed.

3. Position the child/young person in a sitting position. If this is not possible their head should be elevated by at least one pillow. For babies, place the pillow underneath the top of the mattress.

4. Wash and dry your hands thoroughly and put on an apron and gloves.

5. Decant feed if applicable into container or pierce carton/pack with giving set and insert set into the pump. Prime the feeding set as instructed by manufacturer.

6. Set rate and volume as prescribed by the Dietitian

7. Test the position of the tube (please see page16).

8. Remove any stoppers and attach the barrel of an enteral 50ml syringe to the end of the tube. Flush the tube with cooled boiled / sterile water as prescribed.

9. Once flush complete, remove the syringe.

10. Attach feeding set to tube, open any clamps on feeding set and commence feed.

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11. Once feed is complete close all clamps and detach the feeding set.

12. Attach barrel of an enteral 50ml syringe to tube and flush the tube with prescribed amount of cooled boiled /sterile water.

13. Remove syringe and close stopper.

14. Reuse or dispose of feeding set as advised.

15. If a reusable syringe has been used, wash and store as per manufacturers instructions.

16. Dispose of used equipment appropriately.

17. Wash and dry hands thoroughly.

18. Remember to complete bedside documentation if child in hospital.

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Section 3

GASTROSTOMY FEEDING Introduction

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Gastrostomy feeding is commonly used for children who require longer term nutritional support and are unable to take sufficient food and fluids orally. They may have previously had a period of nasogastric feeding. Feeds can be given either by a bolus and/or via an enteral feeding pump. Bolus Feeding via a Gastrostomy Tube Equipment Required

Clean tray/trolley/surface 50ml enteral (‘purple’) syringe Cooled boiled water/sterile water Non-sterile gloves and apron (paid carers and nursing staff) The feed. Check the feed including feed type and expiry date. If the feed is curdled

don’t use. Opened containers of feed should be stored in a fridge and discarded after 24 hours)

Extension set (if required) The Procedure

1. Ensure that everything has been collected and is near to hand.

2. Inform the child/ young person the feed is about to start.

3. Position the child/young person in a sitting position. If this is not possible their head should be elevated by at least one pillow. For babies, place the pillow underneath the top of the mattress.

4. Wash and dry your hands thoroughly, put on apron and gloves.

5. To flush the tube, remove any clamps and attach the barrel of an enteral 50ml syringe to the tube.

6. Pour prescribed amount of cooled boiled water / sterile water into syringe barrel.

7. After the water has been administered, pour feed into the syringe.

8. Continue pouring feed into syringe barrel at rate tolerated by child/ young person.

9. Do not use the plunger to push the water or feed. If the feed is going too fast lower the syringe, if it is too slow then raise the syringe. The average time it should take for the feed to run through is 15-30mins.

10. Once the feed is completed, flush the tube with the recommended amount of cooled boiled / sterile water.

11. Clamp the gastrostomy tube, remove the syringe and remove the extension set if used.

12. If a reusable syringe or extension set is used, wash and store as per manufacturers instructions.

13. Dispose of used equipment appropriately.

14. Wash and dry hands thoroughly.

15. Remember to complete bedside documentation if child in hospital. Pump Feeding via a Gastrostomy Tube

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Equipment Required

Clean tray/trolley/surface 50ml enteral (‘purple’) syringe Cooled boiled water/sterile water Non-sterile gloves and apron (paid carers and nursing staff) The feed. Check the feed (including feed type and expiry date, if the feed is curdled

don’t use. Opened containers of feed should be stored in a fridge and discarded after 24 hours)

Extension set (if required) Enteral feeding pump and giving set The Procedure

1. Ensure that everything you need has been collected and is near to hand.

2. Inform the child/ young person you are now going to start the feed.

3. Position the child/young person in a sitting position. If this is not possible their head should be elevated by at least one pillow. For babies, place the pillow underneath the top of the mattress.

4. Wash and dry your hands thoroughly and put on an apron and gloves

5. Decant feed if applicable into container or pierce carton/pack with giving set and insert set into the pump. Prime the feeding set as instructed by manufacturer.

6. Set rate and volume as prescribed by the Dietitian

7. Attach an extension set if required, attach the barrel of an enteral 50ml syringe to the end of the gastrostomy tube and remove the clamp.

8. Flush the tube with cooled boiled / sterile water as prescribed.

9. Once flush complete, clamp the tube and remove the syringe.

10. Attach feeding set to gastrostomy, open any clamps on feeding set and commence feed.

11. Once feed is complete close all clamps and detach the feeding set

12. Attach barrel of an enteral 50ml syringe to tube and flush the tube with prescribed amount of cooled boiled /sterile water.

13. Clamp the gastrostomy tube and remove syringe and extension set

14. If a reusable syringe or extension set has been used, wash and store as per manufacturers instructions.

15. Dispose of used equipment appropriately.

16. Wash and dry hands thoroughly.

17. Remember to complete bedside documentation if child in hospital.

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Section 4

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REFERENCES Ardill R, Lawrence S, Lee HM, Paxton C, Eyles L and Wilson DC (2010), Regional Trends in Paediatric Home Enteral Tube Feeding 1997-2009, Archives of Disease in Childhood 95 Supp 1 A46-A47 National Patient Safety Agency (2005a) Reducing the Harm Caused by Misplaced Nasogastric Tubes. Patient Safety Alert 05, 21 Feb 2005. National Patient Safety Agency (2005b) Reducing the Harm Caused by Misplaced Naso and Orogastric Feeding Tubes in Babies Under the Care of Neonatal Units. Patient Safety Alert 09, 18 Aug 2005. National Patient Safety Agency (2007) Promoting Safer Measurement and Administration of Liquid Medicines via Oral and Other Enteral Routes. Patient Safety Alert 19 28 March 2007. Ref: NPSA/2007/19. National Patient Safety Agency (2011) Reducing the Harm Caused by Misplaced Nasogastric Feeding Tubes in Adults, Children and Infants. Patient Safety Alert 002, 10 March 2011. Ref: NPSA/2011/PSA002. National Patient Safety Agency (2012a) Harm from Flushing of Nasogastric Tubes Before Confirmation of Placement, Rapid Response Report. 22 March 2012. Ref: NPSA/2012/RRR001. National Patient Safety Agency (2012b) The risk of Harm from children and neonates entangled in Lines, Signals 14 February 2011 Ref:1309. Paxton C, Wade K, Ardill R, Lee HM, Eyles L, Freer Y, Menon G and Wilson DC (2012) Distinctly Different Temporal Trends Exist Between Neonatal and Paediatric Home Enteral Tube Feeding (HETF) in the Same UK Region. Archives of Disease in Childhood 97 Supp 1 A55. QIS (2007) Caring for Children and Young People in the Community Receiving Enteral Tube Feeding. Best Practice Statement, Quality Improvement Scotland, Edinburgh. Sullivan PB, Jusczak E, Bachlet AM, Lambert B, Vernon-Roberts A, Grant HW, et al. Gastrostomy tube feeding in children with cerebral palsy: a prospective, longitudinal study. Developmental Medicine and Child Neurology. 2005, 47(2): 77-85.

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ACKNOWLEDGEMENTS This document has been adapted with permission from NHS Forth Valley and NHS Lanarkshire’s documentation on enteral feeding. The Managed Clinical Network for the West of Scotland Gastroenterology, Hepatology and Nutrition Network would like to thank the following members of the Enteral Feeding Information Group for their contributions to the document. Andrew Barclay Consultant Paediatric Gastroenterologist, Royal Hospital for Sick

Children, NHS Greater Glasgow and Clyde Carolyn Baxter Community Children’s Nurse, NHS Lanarkshire Elaine Buchanan Paediatric Gastroenterology Dietitian, Royal Hospital for Sick Children,

NHS Greater Glasgow and Clyde Caroline Cooper Paediatric Dietitian, Inverclyde, NHS Greater Glasgow and Clyde Ellen Cowie Parent representative, NHS Forth Valley Karen Fraser Data Manager, Royal Hospital for Sick Children, NHS Greater Glasgow

and Clyde Marianne Hayward Head of MCN, Queen Mother’s Hospital Elizabeth Gillespie Community Children’s Nurse, NHS Greater Glasgow and Clyde Michelle Lewis Paediatric Dietitian, NHS Ayrshire and Arran Isobel Macleod Paediatric Nutrition Nurse, Royal Hospital for Sick Children, NHS

Greater Glasgow and Clyde Laura Morrison Clinical Nurse Specialist, NHS Dumfries and Galloway Lynsey Shanks Clinical Nurse Specialist, NHS Ayrshire and Arran Karen Sinclair Clinical Nurse Educator, Royal Hospital for Sick Children, NHS Greater

Glasgow and Clyde Avril Smith Paediatric Gastrostomy Nurse, Royal Hospital for Sick Children, NHS

Greater Glasgow and Clyde

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Section 5

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APPENDIX 1 Administering medication via enteral feeding tubes Discussion should take place with a pharmacist concerning the medication requirements for any child or young person who will have to receive medication via a nasogastric, gastrostomy or jejunal tube. Liquid Medications should always be used wherever possible. If medication is only

available in tablet form, then it should be checked with a pharmacist that it is suitable to be crushed and administered via a nasogastric, gastrostomy or jejunal tube.

Some medications may require the feed to be stopped for a period of time prior to

administration and /or afterwards in order for the medication to be absorbed fully.

If using an NG tube the tube position should always be checked before use (pH less than or equal to 5.5) following the procedure on page16.

Before and after each drug the tube should be flushed with a small amount of

cooled boiled / sterile water. Some medicines cannot be given via a jejunal feeding tube and all medicines should

be discussed with a doctor to ensure they can be administered directly into the small bowel.

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APPENDIX 2 Feed hygiene Carry out hand hygiene in accordance with local infection control guidelines prior to

carrying out any administration of feeds or handling of enteral feeding tubes.

Avoid touching any internal part of the feed container or giving set such as the spike with your hands (non-touch technique).

Pre-packed liquid feeds are sterile until opened so they can be used for up to 24

hours, if good hand hygiene is employed.

Powdered feeds and feeds that have extra ingredients added should not be hanging for more than 4 hours in hospital.

Giving sets must be changed every 24 hours or more frequently if advised by the

Dietitian.

Pump assisted bolus feeds require a new giving set and container for each feed.

Feed containers should not be topped up with feed once feeding has started. Instead the total volume required should be decanted at the start of any feed.

Any unused feed should be discarded down a sink after the above time periods.

Rotate stock so that it does not go out of date.

Store equipment and powdered feed in a dry place as per manufacturer’s

instructions.

Avoid stacking feed next to radiators or in direct sunlight.

Powdered feeds once made up should be stored in the refrigerator on the ward for a maximum of 24 hours.

Opened bottles of ready made feed should be stored in the refrigerator on the ward

for a maximum of 24 hours.

If powdered feeds are being made on the ward this should be done in a clean area and in adherence with local infection control guidelines.

Parents should be advised not to store feeds or equipment in garden sheds or

garages once discharged.

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APPENDIX 3 Supporting information Oral Care Despite children receiving feeds via feeding tubes regular brushing of teeth is essential to prevent dental decay. Current recommendations state that a toothbrush and toothpaste containing 1000ppm fluoride should be used twice a day (www.child-smile.org.uk). Single Use Equipment Items marked ‘single use’ or should not be reused. Colour Blindness In those with red-green colour blindness, the pH test result must be confirmed by another individual.

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APPENDIX 4 Guidance for staff to reduce risk of strangulation caused by enteral feeding lines The National Patient Safety Agency (Signals, 2011) has highlighted the risk of strangulation from enteral feeding lines and this has been assessed as highest overnight or when a child is left unattended. To reduce the risk of strangulation, please adhere to the following guidance:

Remove unnecessary tubing/ cables /cord from the child’s cot/ bedside and regularly review the necessity of overnight equipment.

Reposition necessary tubing/ cables/cords (for example secure through clothing, coil excess tubing.

Feeding regimes should be reviewed regularly as the child grows and develops,

especially at the stage where movement during the night is likely to change.

Reduce the length of tubing in the cot/bed.

If gastrostomy feed, the feeding pump should be positioned at the bottom end of the cot/bed with the giving set thread through the bars rather than dangling over the top of the cot.

If gastrostomy fed, the child should wear appropriate nightwear that allows the

giving set to be thread through the leg of the clothing to the gastrostomy site.

If nasogastric or nasojejunal fed, the feeding pump should be positioned at the top of the cot/bed with the giving set thread through the bars rather than dangling over the top of the cot.

All the pumps/ equipment should be positioned closest to the point of entry into the

body.

Staff should check the safety of the tubing during any overnight interaction with the child.

Adopted from the Aneurin Bevan Health Board protocol for assessing the risk of overnight tube feeding in children (2010)

Developed by West of Scotland Paediatric Gastroenterology, Hepatology and Nutrition Managed Clinical Network (WoSPGHaN).

WoSPGHaN West of Scotland Gastroenterology, Hepatology and Nutrition Network

www.wospghan.scot.nhs.uk

If you would like more information, visit the website www.wospghan.scot.nhs.uk Published: May 2013 Version 1 Updated: February 2014 Version 2 Review Date: December 2015